USMLE Data Analysis

1 Data import and cleaning

In this section I import the data and prepare it for analysis.

Code

```{r setup}
#| warning: false
#| message: false

library(tidyverse)
library(plotly)
library(dplyr)
library(tidyr)
library(knitr)
library(table1) #Create HTML Tables of Descriptive Statistics https://cran.r-project.org/web/packages/table1/vignettes/table1-examples.html
#library(OMTM1) #https://github.com/schildjs/OMTM1/
library(Hmisc)
library(rms) # Regression Modeling Strategies by Frank https://cran.r-project.org/web/packages/rms/index.html
library(modelsummary) #Summary Tables and Plots for Statistical Models and Data: Beautiful, Customizable, and Publication-Ready https://cran.r-project.org/web/packages/modelsummary/index.html
library(scales) # The scales packages provides the internal scaling infrastructure used by ggplot2, and gives you tools to override the default breaks, labels, transformations and palettes. https://scales.r-lib.org
library(viridis) #colors
library(cowplot) #allows me to use plotgrid
library(gridExtra) #adding tables to plots
library(visdat) #shows missing data
library(GGally) #makes pairs plots
library(sandwich) #for robust standard errors
library(gtsummary) #makes the tables look nicer
library(glmnet) #for running LASSO

#if you want to rerun this in your code, change the directory to where you have saved the data locally (do not upload data to github)
setwd("/Users/lisalevoir/BIOS7351_Collab/data_project2") #this line I would need to run in the console
knitr::opts_knit$set(root.dir = "/Users/lisalevoir/BIOS7351_Collab/github/BIOS_Collaboration/project_2_analysis") #now I set global options for knitting, I also had to toggle global options > R Markdown > evaluate chunks in current directory

#import the data
dat <- read.csv("/Users/lisalevoir/BIOS7351_Collab/data_project2/combined_data_203.csv")

#to compare that the merging went as expected
VUMSdat <- read.csv("/Users/lisalevoir/BIOS7351_Collab/data_project2/DATA_VUMS.csv")
HMSdat <- read.csv("/Users/lisalevoir/BIOS7351_Collab/data_project2/DATA_HMS.csv")
UVAdat <- read.csv("/Users/lisalevoir/BIOS7351_Collab/data_project2/DATA_UVA.csv")
```

1.0.1 Inclusion/Exclusion

Criteria to exclude students who most likely took a scored exam:

• Any PhD students (n = 2)

• Any 5th year program students (n = 19)

• M4 students at Vanderbilt (n = 5)

• Students who did not complete either Step survey (n = 2)

• Students who specifically stated they took a scored Step 1 (n=1)

[1] "uworld_percent_step1_1" "uworld_percent_step1_2"
[1] "amboss_percent_step1_1" "amboss_percent_step1_2"
[1] "length_step1_1" "length_step1_2"
[1] "practicetest_step1_1" "practicetest_step1_2"
[1] "full_test_practice_step1_1" "full_test_practice_step1_2"
[1] "push_step1_1" "push_step1_2"
[1] "push_practice_test_step1_1" "push_practice_test_step1_2"
[1] "push_nbme_practice_score_step1_1" "push_nbme_practice_score_step1_2"
[1] "push_uw_practice_score_step1_1" "push_uw_practice_score_step1_2"
[1] "final_nbme_practice_score_step1_1" "final_nbme_practice_score_step1_2"
[1] "final_uw_practice_score_step1_1" "final_uw_practice_score_step1_2"
[1] "score_step1_1" "score_step1_2"
[1] "other_resources_step1_1" "other_resources_step1_2"
[1] "other_step1_1" "other_step1_2"
[1] "changes_step1_1" "changes_step1_2"
[1] "Above is a list of columns I have combined for you. Hope it looks right!"

[1] "uworld_percent_step2_1" "uworld_percent_step2_2"
[1] "amboss_percent_step2_1" "amboss_percent_step2_2"
[1] "length_step2_1" "length_step2_2"
[1] "practicetest_step2_1" "practicetest_step2_2"
[1] "full_test_practice_step2_1" "full_test_practice_step2_2"
[1] "practice_score_step2_1" "practice_score_step2_2"
[1] "practice_test_step2_1" "practice_test_step2_2"
[1] "score_step2_1" "score_step2_2"
[1] "target_score_step2_1" "target_score_step2_2"
[1] "Above is a list of columns I have combined for you. Hope it looks right!"

There were 203 participants after the the clients did data exclusion by hand, as compared to the total survey size which was 182 unique individuals included in the step 1 data.

These are the record IDs that were excluded by the collaborator: VUSM 23, VUSM 60, HMS 37, HMS 41, HMS 49, UVASOM 33, UVASOM 80, UVASOM 84.

For our analysis, I originally included everyone from the 3 school specific data sets. Then, we flagged individuals to remove and I remade the source data set. These are the records IDs that we decided to exclude:

• VU record ids: 23, 26, 39, 40, 54, 3, 8, 12, 49, 60, 62, 64

• HMS record ids: 1, 21, 28, 30, 34, 37, 39, 41, 44, 47, 49, 61

• UVA record ids: 33, 47, 80, 81, 83

Below are tables for Step 1 and Step 2 response inclusion by school:

Code

kable(table(step1_complete$schoolid), caption = "Number of Step 1 responses included by school")

Number of Step 1 responses included by school

Var1	Freq
HMS	50
UVa	79
VU	53

Code

kable(table(step2_complete$schoolid), caption = "Number of Step 2 responses included by school")

Number of Step 2 responses included by school

Var1	Freq
HMS	39
UVa	65
VU	34

Notice that unfortunately for Step 2 analysis, we had to drop 44 individuals who did not report a step 2 score. These raw counts and frequencies of people who did not give a step 2 score (and are therefor not eligible for analysis) are listed by institution below.

Code

# describing the missingness
kable(table(drop_these_with_no_outcome$schoolid), caption = "Number of missing Step 2 scores by institution")

Number of missing Step 2 scores by institution

Var1	Freq
HMS	11
UVa	14
VU	19

Code

num <- as.vector(table(drop_these_with_no_outcome$schoolid))
denom <- as.vector(table(step2_complete$schoolid))
nonresponse_freq <- setNames(c(round(num/denom, 3)), c(names(table(step2_complete$schoolid))))
kable(nonresponse_freq, caption = "frequency of missing step 2 scores by instition")

frequency of missing step 2 scores by instition

	x
HMS	0.282
UVa	0.215
VU	0.559

We also find it helpful to visually profile the missingness in this graphic below. Some of this missingness is due to questions being hierarchical.

Code

######### visually profile missing responses
p1 <- visdat::vis_miss(step1_complete)
p2 <- visdat::vis_miss(step2_complete)

title_gg <- ggdraw() + draw_label("Response missingness for pooled survey results across exam order")
gridded <- plot_grid(p1, p2, label_size = 12, ncol = 2, align = "hv", label_x = 0.5,
          labels = c("Step 1","Step 2"))
plot_grid(title_gg, gridded, nrow = 2, rel_heights = c(0.1, 0.9))

2 Analysis

Note, we plan to use the robust/sandwich variance estimator for regression models. One inclusion criteria is that the outcome variable (“Y”) must be available for a subject to be included in the analysis question (ie. if they did not report a step 2 score, we won’t perform relevant step 2 analysis on them).

Q1 Does order have an impact on Step 2 scores? (ready to report)

We cannot analyze Step 1 since all survey responses reported passing For Step 2 scores, I will perform a linear regression with:

• Y = Step 2 score
• X = factor ( 1 = “step 1 first”, 2 = “step 2 first”, 3 = “only step 1”, 4 = “only step 2”)
• Z = school (need to adjust for this)

Code

step2_complete[ ,"order_factor"]  <- factor(step2_complete$exam_order, levels = c(1,2, 3, 4), labels = c("step 1 first", "step 2 first", "only step 1", "only step 2"))

step2_complete[ ,"which_exam_first"] <- ifelse(step2_complete$order_factor == "step 1 first" | step2_complete$order_factor == "only step 1", 1, 2)

step2_complete[ ,"school_factor"]   <- factor(step2_complete$schoolid, labels = c("HMS", "UVA", "VUMS"))

table(step2_complete$order_factor)

step 1 first step 2 first  only step 1  only step 2 
          71           67            0            0 

Code

table(step2_complete$which_exam_first)

 1  2 
71 67 

Code

exam_order_mod <- lm(formula = score_step2 ~ which_exam_first + school_factor, data = step2_complete)
sqrt(diag(sandwich(exam_order_mod))) #this gives the sandwich variance now set to be the standard error

      (Intercept)  which_exam_first  school_factorUVA school_factorVUMS 
         3.913069          3.239613          3.800480          2.435807 

Code

p_interim <-pt(abs(exam_order_mod$coefficients)/sqrt(diag(sandwich(exam_order_mod))) , df = 134) 
1 - p_interim #here are the p values with using the robust se

      (Intercept)  which_exam_first  school_factorUVA school_factorVUMS 
        0.0000000         0.3913653         0.1454971         0.3440918 

Code

summary(exam_order_mod) %>% tbl_regression()  #model summary for reporting

Characteristic	Beta	95% CI1	p-value
which_exam_first	0.90	-8.1, 9.8	0.8
school_factor
HMS	—	—
UVA	-4.0	-14, 5.9	0.4
VUMS	-0.98	-7.9, 6.0	0.8
1 CI = Confidence Interval

Based on the model output (p values), there doesn’t appear to be any signifigant associations between exam order and the score for Step 2. Since the R^2 value is essentially 0, I conclude that there was no effect of exam order on step 2 scores.

Q2 What factors affect Step 2 score? (do not report this yet until we decide)

Again, we cannot analyze Step 1 scores since all respondents reported passing.

Based on our SAP, if there are any covariates with more than 30% of responses missing, we will drop that variable or populate it with 0, depending on context. For example, the percent of Amboss questions completed will be filled with 0 for people who didn’t answer that they used Amboss since it seems safe to assume they didn’t complete any of the Amboss questions. For people who did select that they used Amboss but didn’t answer a percentage will be treated as missing

If less than 30% are missing, I may consider performing bootstrap sampling of known values to replace missing values.

After accounting for missingness, I will assess for co-linearity of the predictors (ie. correlation) using VIF. If there is high co-linearity, we will use LASSO to perform variable selection. If there is no evidence of concerning levels of colinearity, I will proceed with linear regression.

Code

#here I am creating the cleaned Uworld and Amboss variables. if they did not check that they used it, the percentage is set to 0.
# if they did use it then the next ifelse checks if there is an NA where there should be a percent
# if there is an NA where there should be a percent, we maintain this NA. If there is not, then we can report the percentage.
# same process for uworld
step2_complete <- step2_complete %>% mutate(amboss_clean = ifelse(I.amboss == 0, 0, 
                                    ifelse(is.na(step2_complete$amboss_percent_step2) == TRUE, NA, step2_complete$amboss_percent_step2)),
                                    
                                    uworld_clean = ifelse(I.uworld == 0, 0, 
                                    ifelse(is.na(step2_complete$uworld_percent_step2 ) == TRUE, NA, step2_complete$uworld_percent_step2)))

#inspecting percent missing, it seems like most responses are now complete enough for analysis
step2_complete$amboss_percent_step2 <- ifelse(is.na(step2_complete$amboss_percent_step2) == TRUE, 0, step2_complete$amboss_percent_step2)
class(step2_complete$practicetest_step2) <- "integer"

step2_complete[,"on_target"] <-  factor(step2_complete$target_score_step2, levels = c(1,2,3), labels = c("at target", "above target", "below target"))


# I looked into the difference between practice_test_step2 (the final practice test I took before my exam was... 8 options) and practicetest_step2 (text response of how many practice tests did you take before step 2).
# I decided to use practicetest_step2 (text response of how many practice tests did you take before step 2) but extract and recode it as numeric below
step2_complete[, "practice_test_2_clean"] <- ifelse(is.na(step2_complete$practicetest_step2) == TRUE, NA, substr(step2_complete$practicetest_step2, start = 1, stop = 1))
step2_complete[, "number_of_practice_tests"] <- as.numeric(step2_complete$practice_test_2_clean) #I want to include the number of practice tests as just one numeric covariate, not coded as a factor like it is in practice_test_2_clean

step2_complete$full_practice_test <- factor(step2_complete$full_test_practice_step2 , levels = c(1:4), labels = c("Yes and I'm glad I did", "Yes and it was unnecessary", "No and I wish I did", "No and I'm glad I did not"))
step2_complete$simulate_full_practice <- ifelse(step2_complete$full_test_practice_step2 <= 2, 1, 0)
step2_complete$simulate_full_practice <- factor(step2_complete$simulate_full_practice, levels = c(0, 1), labels = c("No", "Yes"))
step2_complete$length_step2 <- factor(step2_complete$length_step2 , levels = c(1:6), labels = c("less than 1 week", "1-2 weeks", "3-4 weeks", "5-6 weeks", "7-8 weeks", "more than 8 weeks"))


######## profile missingness in the step 2 data and address
step2_profile <- step2_complete %>% relocate(c(score_step2, uworld_clean, amboss_clean, length_step2, simulate_full_practice, practice_score_step2, number_of_practice_tests, school_factor), .before = schoolid)

percents_missing <-round(colSums(is.na(step2_profile))/nrow(step2_profile), 3)*100
kable(percents_missing, caption = "Percent missing observations for pooled Step 2 survey")

Percent missing observations for pooled Step 2 survey

	x
record_id	0.0
score_step2	0.0
uworld_clean	1.4
amboss_clean	9.4
length_step2	1.4
simulate_full_practice	0.0
practice_score_step2	29.7
number_of_practice_tests	5.1
school_factor	0.0
schoolid	0.0
exam_order	0.0
uworld_percent_step2	1.4
amboss_percent_step2	0.0
practicetest_step2	5.1
full_test_practice_step2	0.0
practice_test_step2	29.0
target_score_step2	0.0
I.uworld	0.0
I.firstaid	0.0
I.anki	0.0
I.sketchy	0.0
I.amboss	0.0
I.pathoma	0.0
I.boardsbeyond	0.0
I.other	0.0
order_factor	0.0
which_exam_first	0.0
on_target	0.0
practice_test_2_clean	5.1
full_practice_test	0.0

Multiple linear regression with:

• Y = Step 2 score (from “What was your 3-digit score on the official Step 2 exam?”)

• X1 = % UWorld (recoded from “Approximately what % of UWorld did you complete during your protected study period for step 2?”)

• X2 = % Amboss (recoded from “Approximately what % of the Amboss question bank did you complete during your Step 2 protected study period?”)

• X3 = length study (factor from “How long did you study for Step 2 during a protected study period?”)

• X4 = number of practice tests (recoded from a text answer from “How many total practice tests did you take before Step 2?”)

• X5 = full test day (yes/no code as binary from “Did you simulate a full Step 2 test day experience, e.g. 8 blocks of 40 UWorld questions or 2 of the 4-section practice tests?”)

• X6 = final practice score (What was your 3 digit score on the final practice test you took before the Step 2 exam?)

• Z = School (need to adjust for this in order to remove any influence)

Careful to note that not all cases are complete - for example there are 399 responses in the complete step 2 dataset, of which for the number of practice tests taken, 108 are missing and 291 have a response recorded.

Below I report the model results, sandwich variance, and VIF for step 2 scores model. After that, I show descriptive statistics for predictors and the outcome that was included in the model.

Code

mod_step2_scores <- lm(score_step2 ~ uworld_clean + amboss_clean + length_step2 + simulate_full_practice + practice_score_step2 + number_of_practice_tests + school_factor, data = step2_complete) 
summary(mod_step2_scores)

Call:
lm(formula = score_step2 ~ uworld_clean + amboss_clean + length_step2 + 
    simulate_full_practice + practice_score_step2 + number_of_practice_tests + 
    school_factor, data = step2_complete)

Residuals:
    Min      1Q  Median      3Q     Max 
-21.360  -3.463   1.966   5.068  15.498 

Coefficients:
                                Estimate Std. Error t value Pr(>|t|)    
(Intercept)                   111.950778  18.543622   6.037 6.22e-08 ***
uworld_clean                    0.003943   0.044241   0.089   0.9292    
amboss_clean                    0.041176   0.042959   0.959   0.3410    
length_step25-6 weeks           1.930819   2.221260   0.869   0.3876    
length_step27-8 weeks          -4.190772   2.771947  -1.512   0.1349    
length_step2more than 8 weeks  -7.817921   6.423664  -1.217   0.2276    
simulate_full_practiceYes       0.410541   2.165465   0.190   0.8502    
practice_score_step2            0.599139   0.071590   8.369 3.14e-12 ***
number_of_practice_tests       -1.156330   0.672732  -1.719   0.0899 .  
school_factorUVA                0.845109   2.534346   0.333   0.7398    
school_factorVUMS              -1.417165   2.459452  -0.576   0.5663    
---
Signif. codes:  0 '***' 0.001 '**' 0.01 '*' 0.05 '.' 0.1 ' ' 1

Residual standard error: 8.204 on 72 degrees of freedom
  (55 observations deleted due to missingness)
Multiple R-squared:  0.5603,    Adjusted R-squared:  0.4992 
F-statistic: 9.174 on 10 and 72 DF,  p-value: 1.401e-09

Code

sqrt(diag(sandwich(mod_step2_scores))) #this gives the sandwich variance now set to be the standard error

                  (Intercept)                  uworld_clean 
                  18.45023526                    0.03322315 
                 amboss_clean         length_step25-6 weeks 
                   0.03299386                    1.77501063 
        length_step27-8 weeks length_step2more than 8 weeks 
                   2.47990055                   11.23193869 
    simulate_full_practiceYes          practice_score_step2 
                   2.02673676                    0.06825513 
     number_of_practice_tests              school_factorUVA 
                   0.52383520                    2.46089715 
            school_factorVUMS 
                   2.06863427 

Code

p_interim <-pt(abs(mod_step2_scores$coefficients)/sqrt(diag(sandwich(mod_step2_scores))) , df = 72) 
1 - p_interim #here are the p values with using the robust se

                  (Intercept)                  uworld_clean 
                 2.742215e-08                  4.529325e-01 
                 amboss_clean         length_step25-6 weeks 
                 1.080370e-01                  1.401603e-01 
        length_step27-8 weeks length_step2more than 8 weeks 
                 4.768688e-02                  2.443211e-01 
    simulate_full_practiceYes          practice_score_step2 
                 4.200242e-01                  2.706724e-13 
     number_of_practice_tests              school_factorUVA 
                 1.523573e-02                  3.661435e-01 
            school_factorVUMS 
                 2.477489e-01 

Code

vif(mod_step2_scores)

                 uworld_clean                  amboss_clean 
                     1.227399                      1.236755 
        length_step25-6 weeks         length_step27-8 weeks 
                     1.503404                      1.609434 
length_step2more than 8 weeks     simulate_full_practiceYes 
                     1.196735                      1.188729 
         practice_score_step2      number_of_practice_tests 
                     1.163156                      1.221483 
             school_factorUVA             school_factorVUMS 
                     1.828295                      1.570226 

Code

mod_step2_scores %>% tbl_regression() #this makes a cleaner looking summary table

Characteristic	Beta	95% CI1	p-value
uworld_clean	0.00	-0.08, 0.09	>0.9
amboss_clean	0.04	-0.04, 0.13	0.3
length_step2
3-4 weeks	—	—
5-6 weeks	1.9	-2.5, 6.4	0.4
7-8 weeks	-4.2	-9.7, 1.3	0.13
more than 8 weeks	-7.8	-21, 5.0	0.2
simulate_full_practice
No	—	—
Yes	0.41	-3.9, 4.7	0.9
practice_score_step2	0.60	0.46, 0.74	<0.001
number_of_practice_tests	-1.2	-2.5, 0.18	0.090
school_factor
HMS	—	—
UVA	0.85	-4.2, 5.9	0.7
VUMS	-1.4	-6.3, 3.5	0.6
1 CI = Confidence Interval

now the significant coefficients are more numerous in the complete case analysis above

Now showing the same the model with imputed missing values.

Code

## model variables were uworld_clean + amboss_clean + length_step2 + simulate_full_practice + practice_score_step2 + number_of_practice_tests + school_factor
# with missingness in uworld_clean, amboss_clean, length_step2, practice_score_step2, and number_of_practice_tests

step2_impute <-
  step2_complete %>% select(
    score_step2,
    uworld_clean,
    amboss_clean,
    length_step2,
    simulate_full_practice,
    practice_score_step2,
    number_of_practice_tests,
    school_factor
  )

# #imputing missing values (replace the NA in columns using the old fashioned matrix operation dt$columns[is.na]= vector of number)
# step2_impute[which(is.na(step2_impute$uworld_clean) == TRUE), "uworld_clean"] <- sample(step2_impute$uworld_clean, size = sum(is.na(step2_impute$uworld_clean)))
# step2_impute[which(is.na(step2_impute$amboss_clean) == TRUE), "amboss_clean"] <- sample(step2_impute$amboss_clean, size = sum(is.na(step2_impute$amboss_clean)))
# step2_impute[which(is.na(step2_impute$length_step2) == TRUE), "length_step2"] <- sample(step2_impute$length_step2, size = sum(is.na(step2_impute$length_step2)))
# step2_impute[which(is.na(step2_impute$practice_score_step2) == TRUE), "practice_score_step2"] <- sample(step2_impute$practice_score_step2, size = sum(is.na(step2_impute$practice_score_step2)))
# step2_impute[which(is.na(step2_impute$number_of_practice_tests) == TRUE), "number_of_practice_tests"] <- sample(step2_impute$number_of_practice_tests, size = sum(is.na(step2_impute$number_of_practice_tests)))

step2_impute = mice::mice(step2_impute,m=1,method='sample') %>% complete #better way to impute according to Jeffrey

 iter imp variable
  1   1  uworld_clean  amboss_clean  length_step2  practice_score_step2  number_of_practice_tests
  2   1  uworld_clean  amboss_clean  length_step2  practice_score_step2  number_of_practice_tests
  3   1  uworld_clean  amboss_clean  length_step2  practice_score_step2  number_of_practice_tests
  4   1  uworld_clean  amboss_clean  length_step2  practice_score_step2  number_of_practice_tests
  5   1  uworld_clean  amboss_clean  length_step2  practice_score_step2  number_of_practice_tests

Warning: Number of logged events: 20

Code

#this is the number of missingness
kable(colSums(is.na(step2_complete[,c("uworld_clean", "amboss_clean", "length_step2", "simulate_full_practice", "practice_score_step2", "number_of_practice_tests", "school_factor")])), caption = "Missingness before imputation")

Missingness before imputation

	x
uworld_clean	2
amboss_clean	13
length_step2	2
simulate_full_practice	0
practice_score_step2	41
number_of_practice_tests	7
school_factor	0

Missingness after imputation to confirm the random sampling replacement worked

Code

colSums(is.na(step2_impute)) #missingness after imputation - should all be 0's

             score_step2             uworld_clean             amboss_clean 
                       0                        0                        0 
            length_step2   simulate_full_practice     practice_score_step2 
                       0                        0                        0 
number_of_practice_tests            school_factor 
                       0                        0 

Code

# here is are two ways to confirm the change was as expected (uncomment to see them in your console):
# cbind(step2_impute$length_step2, step2_complete$length_step2)
# cbind(step2_impute$practice_score_step2, step2_complete$practice_score_step2)
mod_impute_step2_scores <- lm(score_step2 ~ uworld_clean + amboss_clean + length_step2 + simulate_full_practice + practice_score_step2 + number_of_practice_tests + school_factor, data = step2_impute) 
#summary(mod_impute_step2_scores)

#calculating the p values using robust standard error:
sqrt(diag(sandwich(mod_impute_step2_scores))) #this gives the sandwich variance now set to be the standard error

                  (Intercept)                  uworld_clean 
                  24.72879215                    0.03151285 
                 amboss_clean         length_step23-4 weeks 
                   0.03108516                    3.02814857 
        length_step25-6 weeks         length_step27-8 weeks 
                   3.54082891                    3.58876443 
length_step2more than 8 weeks     simulate_full_practiceYes 
                  12.91551214                    1.58303850 
         practice_score_step2      number_of_practice_tests 
                   0.08974241                    0.44948636 
             school_factorUVA             school_factorVUMS 
                   2.04459538                    1.98323286 

Code

p_interim <-pt(abs(mod_impute_step2_scores$coefficients)/sqrt(diag(sandwich(mod_impute_step2_scores))) , df = 114) 
1 - p_interim #here are the p values with using the robust se

                  (Intercept)                  uworld_clean 
                 4.023370e-04                  1.648167e-01 
                 amboss_clean         length_step23-4 weeks 
                 1.884187e-01                  1.687539e-13 
        length_step25-6 weeks         length_step27-8 weeks 
                 3.560463e-11                  1.714076e-09 
length_step2more than 8 weeks     simulate_full_practiceYes 
                 4.032731e-01                  3.462829e-01 
         practice_score_step2      number_of_practice_tests 
                 5.887979e-10                  8.706923e-02 
             school_factorUVA             school_factorVUMS 
                 1.641849e-01                  7.591805e-02 

Code

#here this shows there's and issue with the new VIF because of colinearity
vif(mod_impute_step2_scores)

                 uworld_clean                  amboss_clean 
                     1.220557                      1.091971 
        length_step23-4 weeks         length_step25-6 weeks 
                    36.994288                     37.757367 
        length_step27-8 weeks length_step2more than 8 weeks 
                    23.257971                      4.627141 
    simulate_full_practiceYes          practice_score_step2 
                     1.150609                      1.259714 
     number_of_practice_tests              school_factorUVA 
                     1.172468                      1.981345 
            school_factorVUMS 
                     1.588427 

Code

#mod_impute_step2_scores %>% tbl_regression() #this makes a cleaner looking summary table

Here is where I run the LASSO and the final model we want to report on for Q2:

Code

## Lasso

set.seed(123123)
my_design_mat <- model.matrix(score_step2~uworld_clean+amboss_clean+as.factor(length_step2)+as.factor(simulate_full_practice)+practice_score_step2+number_of_practice_tests+as.factor(school_factor),step2_impute)

cv.glmnet(my_design_mat[,-1],step2_impute$score_step2,family = 'gaussian',standardize = T,type.measure = 'mse', lambda = seq(1e-2,1e+1,len=1e+4)) #  based on this output, we can build the model based on 0.262

Call:  cv.glmnet(x = my_design_mat[, -1], y = step2_impute$score_step2,      lambda = seq(0.01, 10, len = 10000), type.measure = "mse",      family = "gaussian", standardize = T) 

Measure: Mean-Squared Error 

    Lambda Index Measure    SE Nonzero
min  1.172  8837   152.0  54.1       4
1se 10.000     1   205.8 105.3       1

Code

model = glmnet(my_design_mat[,-1],step2_impute$score_step2,family = 'gaussian',standardize = T,lambda = 0.262)

coef(model)

13 x 1 sparse Matrix of class "dgCMatrix"
                                                   s0
(Intercept)                              111.20513429
uworld_clean                               0.02922474
amboss_clean                               0.01880629
as.factor(length_step2)1-2 weeks         -21.42584353
as.factor(length_step2)3-4 weeks           .         
as.factor(length_step2)5-6 weeks           0.44450281
as.factor(length_step2)7-8 weeks          -0.93340918
as.factor(length_step2)more than 8 weeks -20.63848410
as.factor(simulate_full_practice)Yes       .         
practice_score_step2                       0.58426347
number_of_practice_tests                  -0.44970010
as.factor(school_factor)UVA               -0.59599241
as.factor(school_factor)VUMS              -1.27680446

Code

#now I need to make a model with a more limited set of predictors (this will stay the same since we set the seed)
#recode length step 2 to have indicators
step2_LASSO <- step2_impute %>% mutate(study1.2.weeks = case_when(length_step2 == "1-2 weeks" ~ 1, TRUE ~ 0), 
                                       study5.6.weeks = case_when(length_step2 == "5-6 weeks" ~ 1, TRUE ~ 0), 
                                       study7.8.weeks = case_when(length_step2 == "7-8 weeks" ~ 1, TRUE ~ 0), 
                                       study8.plus.weeks = case_when(length_step2 == "more than 8 weeks" ~ 1, TRUE ~ 0))

## here is where I would run a model with the selected predictors
mod_LASSO_step2_scores <- lm(score_step2 ~ uworld_clean + amboss_clean + study1.2.weeks + study5.6.weeks + study7.8.weeks + study8.plus.weeks + simulate_full_practice + practice_score_step2 + number_of_practice_tests + school_factor, data = step2_LASSO) 

## then make a summary of that model's output and the new robust se and p values
summary(mod_LASSO_step2_scores)

Call:
lm(formula = score_step2 ~ uworld_clean + amboss_clean + study1.2.weeks + 
    study5.6.weeks + study7.8.weeks + study8.plus.weeks + simulate_full_practice + 
    practice_score_step2 + number_of_practice_tests + school_factor, 
    data = step2_LASSO)

Residuals:
     Min       1Q   Median       3Q      Max 
-27.3081  -3.8669   0.6804   5.2062  28.0649 

Coefficients:
                           Estimate Std. Error t value Pr(>|t|)    
(Intercept)               110.08140   13.91637   7.910 1.13e-12 ***
uworld_clean                0.03085    0.03670   0.841 0.402168    
amboss_clean                0.02758    0.03498   0.788 0.431957    
study1.2.weeks            -24.93300    9.65587  -2.582 0.010962 *  
study5.6.weeks              0.53818    1.89348   0.284 0.776702    
study7.8.weeks             -1.93473    2.50843  -0.771 0.441978    
study8.plus.weeks         -21.76284    6.02509  -3.612 0.000437 ***
simulate_full_practiceYes   0.62748    1.77287   0.354 0.723978    
practice_score_step2        0.59486    0.05311  11.201  < 2e-16 ***
number_of_practice_tests   -0.61470    0.56714  -1.084 0.280494    
school_factorUVA           -2.00700    2.18485  -0.919 0.360062    
school_factorVUMS          -2.86129    2.26615  -1.263 0.209057    
---
Signif. codes:  0 '***' 0.001 '**' 0.01 '*' 0.05 '.' 0.1 ' ' 1

Residual standard error: 9.102 on 126 degrees of freedom
Multiple R-squared:  0.6425,    Adjusted R-squared:  0.6113 
F-statistic: 20.59 on 11 and 126 DF,  p-value: < 2.2e-16

Q3 What is associated (in this data) with pushing back a Step 1 exam date? (ready to report)

Here, I will perform logistic regression with

Y = yes or no (1 = yes, 2 = no for “push_step1”)

There may not be sufficient data on this since only 20 people responded that they decided to push back Step 1. The factors that were measured are:

• push remember step1 (1 = I only remember the form name, 2 = I only remember the score, 3 = I remember the form name and the score, 4 = I don’t remember either) - we decided not to include this variable (can change later if desired)

• push score only step 1 (1 = NBME, 2 = Uworld)

• push practice test step 1 ( 1 - 8 listing various exams)

• push nbme practice score (from 0 to 100%)

• push uw practice score (from 180 to 300)

Listing variables by name and if I have included them:

• “push_step1_1” yes

• “push_remember_step1_1” not included b/c a precursor question

• “push_score_only_step1_1” not currently included but could be

• “push_practice_test_step1_1” yes

• “push_nbme_practice_score_step1_1” yes

• “push_uw_practice_score_step1_1” yes

Code

step1_complete$push_step1 <- ifelse(step1_complete$push_step1 == 2 | is.na(step1_complete$push_step1) ==TRUE, 2, 1) #recording the NA's to be "No" (they did not push back step 1)
step1_complete$push_step1_label <- factor(step1_complete$push_step1, levels = c(1, 2), labels = c("Yes", "No")) #making a nice descriptive label

#did_push_df <- step1_complete %>% filter(push_step1_label == "Yes")
#dat %>% filter(!is.na(push_remember_step1_1))

step1_complete$push_practice_test_step1 <- factor(step1_complete$push_practice_test_step1, levels = c(1:8), labels = c("NBME 25", "NBME 26", "NBME 27", "NBME 28", "NBME 29", "NBME 30", "UWorld 1", "UWorld 2"))

#making labels for descriptive table
units(step1_complete$push_uw_practice_score_step1) <- "score units"
units(step1_complete$push_nbme_practice_score_step1) <- "percent"
label(step1_complete$push_practice_test_step1) <- "exam that triggered pushing back"
label(step1_complete$push_nbme_practice_score_step1) <- "NBME P(passing) that triggered pushing back"
label(step1_complete$push_uw_practice_score_step1) <- "3 digit UWorld score that triggered pushing back"
caption <- "Description of indiviuals that pushed back Step 1"
table1(~ push_practice_test_step1 + push_uw_practice_score_step1 + push_nbme_practice_score_step1 |push_step1_label, data=step1_complete, topclass="Rtable1-zebra")

	Yes (N=20)	No (N=162)	Overall (N=182)
exam that triggered pushing back
NBME 25	0 (0%)	0 (0%)	0 (0%)
NBME 26	0 (0%)	0 (0%)	0 (0%)
NBME 27	1 (5.0%)	0 (0%)	1 (0.5%)
NBME 28	1 (5.0%)	0 (0%)	1 (0.5%)
NBME 29	0 (0%)	0 (0%)	0 (0%)
NBME 30	0 (0%)	0 (0%)	0 (0%)
UWorld 1	0 (0%)	0 (0%)	0 (0%)
UWorld 2	1 (5.0%)	0 (0%)	1 (0.5%)
Missing	17 (85.0%)	162 (100%)	179 (98.4%)
3 digit UWorld score that triggered pushing back (score units)
Mean (SD)	180 (NA)	NA (NA)	180 (NA)
Median [Min, Max]	180 [180, 180]	NA [NA, NA]	180 [180, 180]
Missing	19 (95.0%)	162 (100%)	181 (99.5%)
NBME P(passing) that triggered pushing back (percent)
Mean (SD)	65.6 (18.3)	NA (NA)	65.6 (18.3)
Median [Min, Max]	67.5 [30.0, 87.0]	NA [NA, NA]	67.5 [30.0, 87.0]
Missing	12 (60.0%)	162 (100%)	174 (95.6%)

Descriptive Statistics (ready to report)

Descriptive statistics will be reported in total and not by school (as requested by the collaborators).

Looking at the data dictionary, we are given final_nbme_practice _score_step1 and final_uw_practice_s core_step1 which are two different covariates which are ONLY in Step 1. These specific questions were not included for step 2, instead there is a question for practice_score_step2, which I included in the model for step 2 score predictors above and will make a plot in this section.

Since everyone passed step 1, I did not run a regression model that included these covariates. Instead, I will make a frequency table.

Code

# Here is how I am planning to organize it:
# 1   Question banks
#       -   % UWorld for step 1 and 2
#       -   % Amboss for step 1 and 2
# 2   length of study for step 1 and step 2 (barplot with frequency table)
# 3   # of practice tests (recoded from a text answer from "How many total practice tests did you take before Step 2?")
# 4   number of practice tests histogram (among the people who answered the question) for step 1
# 5   full test day as factor from "Did you simulate a full Step 2 test day experience, e.g. 8 blocks of 40 UWorld questions or 2 of the 4-section practice tests?" "full_practice_test"
# 6   histogram of Step 2 scores
# 7   frequency table of Step 1 scores
# 8   what resources are most widely used barplot
# 9   practice score step 2
# 10   summarize comments for other_resources, other_step, changes_step
# 11 Practice Scores for Step 1
#  11a probability of passing for step 1
#   11b  final_nbme_practice_score_step1 is a percent from 0 to 100
#   11c   final_uw_practice_score_step1 is a 3 digit UWorld score for step 1

####  and these are covered in other plots already (as numbered)
# 11b looking at the data dictionary, we are given final_nbme_practice _score_step1 and final_uw_practice_s core_step1 which are two different covariates which are ONLY in Step 1.
# 7 Since everyone passed step 1, I did not run a regression model that included these covariates. Instead, I will make a plot to show this in descriptive data.
# 9 These specific questions were not included for step 2, instead there is a question for practice_score_step2, which I do include in the model for step 2 score predictors above.

############################ now see the plots below as organized by the list I made above
# 1   Question banks
#       -   % UWorld for step 1 and 2
#       -   % Amboss for step 1 and 2
qudf <- data.frame(amount = c(step1_complete$uworld_percent_step1, 
                             step1_complete$amboss_percent_step1, 
                             step2_complete$uworld_percent_step2, 
                             step2_complete$amboss_percent_step2), 
                  step_exam = c(rep("Step 1", times = nrow(step1_complete)*2), 
                                rep("Step 2", times = nrow(step2_complete)*2)), 
                  resource_name = c(rep("UWorld", times = nrow(step1_complete)), 
                                    rep("Amboss", times = nrow(step1_complete)), 
                                    rep("Uworld", times = nrow(step2_complete)), 
                                    rep("Amboss", times = nrow(step2_complete))))

ggplot(qudf, aes(amount)) + geom_histogram() + 
  facet_wrap(~step_exam + resource_name) + 
  theme_minimal() + 
  scale_color_brewer() + 
  labs(title = "What percent of the UWorld/Amboss question bank did you complete?")

`stat_bin()` using `bins = 30`. Pick better value with `binwidth`.

Warning: Removed 209 rows containing non-finite values (`stat_bin()`).

Length of study for each exam

Code

# 2   length of study for step 1 and step 2 (barplot with frequency table)
       # for step 1
step1_complete$length_step1_lab <- factor(step1_complete$length_step1 , levels = c(1:6), labels = c("less than 1 week", "1-2 weeks", "3-4 weeks", "5-6 weeks", "7-8 weeks", "more than 8 weeks")) #make the factor labels which wasn't done before

ggplot(data.frame(step1_complete), aes(x=factor(length_step1_lab))) + 
  geom_bar() + 
  theme_minimal() + 
  geom_text(aes(label = ..count..), stat = "count", vjust = 1.5, colour = "white") +
  xlab("Time") +
  ylab("Frequency") + 
  ggtitle("How long did you study for Step 1 during a protected study period?", subtitle=
    paste(" answered = ",
     sum(!is.na(step1_complete$length_step1)), 
     " missing = ", 
     sum(is.na(step1_complete$length_step1))))

Warning: The dot-dot notation (`..count..`) was deprecated in ggplot2 3.4.0.
ℹ Please use `after_stat(count)` instead.

Code

       # for step 2
ggplot(data.frame(step2_complete), aes(x=length_step2)) + 
  geom_bar() + 
  theme_minimal() + 
  geom_text(aes(label = ..count..), stat = "count", vjust = 1.5, colour = "white") +
  xlab("Time") +
  ylab("Frequency") + 
  ggtitle("How long did you study for Step 2 during a protected study period?", subtitle=
    paste(" answered = ",
     sum(!is.na(step2_complete$length_step2)), 
     " missing = ", 
     sum(is.na(step2_complete$length_step2))))

Step 2 # of practice tests

Code

# 3   # of practice tests (recoded from a text answer from "How many total practice tests did you take before Step 2?")
ggplot(aes(x = number_of_practice_tests), data= step2_complete) + 
  geom_bar() + 
  theme_minimal() +
  xlab("Number of tests") + 
  ylab("Frequency") + 
  ggtitle("How many total practice tests did you take before Step 2?", subtitle=
    paste(" answered = ",
     sum(!is.na(step2_complete$number_of_practice_tests)), 
     " missing = ", 
     sum(is.na(step2_complete$number_of_practice_tests))))

Warning: Removed 7 rows containing non-finite values (`stat_count()`).

Step 1 # of practice tests

Code

# 4   number of practice tests histogram (among the people who answered the question) for step 1
ggplot(aes(x = practicetest_step1), data= step1_complete) + 
  geom_bar() + 
  scale_color_brewer(palette = "Paired") + 
  theme_minimal() +
  xlab("Number of tests") + 
  ylab("Frequency") + 
  ggtitle("How many total practice tests did you take before Step 1?", subtitle=
    paste(" answered = ",
     sum(!is.na(step1_complete$practicetest_step1)), 
     " missing = ", 
     sum(is.na(step1_complete$practicetest_step1))))

Warning: Removed 29 rows containing non-finite values (`stat_count()`).

Code

## number of practice tests histogram (among the people who answered the question)

Simulating a full test day

Code

# 5   full test day as factor from "Did you simulate a full Step 2 test day experience, e.g. 8 blocks of 40 UWorld questions or 2 of the 4-section practice tests?" "full_practice_test"
ggplot(aes(x = full_practice_test), data= step2_complete) + 
  coord_flip() +
  scale_color_brewer(palette = "Greens") + 
  geom_bar() + 
  theme_minimal() +
  xlab("") + 
  ylab("Frequency") + 
    ggtitle("Did you simulate a full Step 2 test day experience, e.g. 8 blocks \n of 40 UWorld questions or 2 of the 4-section practice tests?", subtitle=
        paste(" answered = ",
         sum(!is.na(step2_complete$full_practice_test)), 
         " missing = ", 
         sum(is.na(step2_complete$full_practice_test))))

Step 2 scores

Code

# 6   histogram of Step 2 scores
ggplot(step2_complete, aes(x = score_step2)) +
  geom_histogram(bins = 30) + 
  theme_minimal() + 
  scale_color_brewer(palette = "Greens") + 
  xlab("Step 2 Score") + 
  ylab("Count") + 
  ggtitle("Frequency of reported Step 2 Scores", subtitle=
        paste(" answered = ",
         sum(!is.na(step2_complete$score_step2)), 
         " missing = ", 
         sum(is.na(step2_complete$score_step2)), 
         "since this was an analysis inclusion condition"))

Step 1 scores

Code

# 7   frequency table of Step 1 scores
kable(table(step1_complete$score_step1), caption = "Frequency of passing Step 1") # would be nice to have a way to summarize these in the same table, but this can just be remade with a table in Word

Frequency of passing Step 1

Var1	Freq
1	154

Code

kable(table(is.na(step1_complete$score_step1)), caption = "True indicates missing values for Step 1 score")

True indicates missing values for Step 1 score

Var1	Freq
FALSE	154
TRUE	28

Resources use

Code

# 8   what resources are most widely used barplot 
resources_2 <- step2_complete %>% select(I.uworld:I.other) %>% summarise(across(everything(), ~ sum(.)))

resources_1 <- step1_complete %>% select(I.uworld:I.other) %>% summarise(across(everything(), ~ sum(.)))

rdf <- data.frame(amount = c(t(resources_1), t(resources_2)), step_exam = c(rep("Step 1", 8), rep("Step 2", 8)), 
                  resource_name = rep(c("Uworld", "First Aid", "Anki", "Sketchy", "Amboss", "Pathoma", "Boards and Beyond", "Other"), times = 2))

res_freq2 <- resources_2/dim(step2_complete)[1]
res_freq1 <- resources_1/dim(step1_complete)[1]
rdf_freq <- data.frame(amount = c(t(res_freq1), t(res_freq2)), step_exam = c(rep("Step 1", 8), rep("Step 2", 8)), 
                  resource_name = rep(c("Uworld", "First Aid", "Anki", "Sketchy", "Amboss", "Pathoma", "Boards and Beyond", "Other"), times = 2))

# http://www.sthda.com/english/wiki/ggplot2-barplots-quick-start-guide-r-software-and-data-visualization used this as a guide
#what resources are most widely used? I want to sort this barplot in order of frequency but for some reason this wasn't working for me with reorder()
ggplot(data=rdf, aes(x=resource_name, y=amount, fill = step_exam))  +
  geom_bar(stat="identity", position=position_dodge()) + 
  coord_flip() +
  xlab("") + 
  ylab("Count") +
  scale_fill_brewer(palette="Paired", name = "") +
  theme_minimal()  + ggtitle("Which resources are most widely used by Step 1/2?") 

Code

ggplot(data=rdf_freq, aes(x=resource_name, y=amount, fill = step_exam))  +
  geom_bar(stat="identity", position=position_dodge()) + 
  coord_flip() +
  xlab("") + 
  ylab("Proportion") +
  scale_fill_brewer(palette="Paired", name = "") +
  theme_minimal()  + ggtitle("Which resources are most widely used by Step 1/2?") 

Code

# 9 practice score step 2 (3 digit score)
ggplot(step2_complete, aes(x = practice_score_step2)) +
  geom_histogram(bins = 30) + 
  theme_minimal() + scale_color_brewer(palette = "Greens") + 
  xlab("Final Step 2 Practice Score") + 
  ylab("Count") + 
  ggtitle("What was your 3 digit score on the final practice test \n you took before the Step 2 exam?", subtitle=paste(" answered = ", sum(!is.na(step2_complete$practice_score_step2)), " missing = ", sum(is.na(step2_complete$practice_score_step2))))

Warning: Removed 41 rows containing non-finite values (`stat_bin()`).

Summarizing comments for other_resources, other_step, changes_step

Code

# 10   summarize comments for other_resources, other_step, changes_step
    ## summarize comments (other_resources, other_step, changes_step)
    #"other_resources_step1"           "other_step1"                     "changes_step1"   
    kable(table(step1_complete$other_resources_step1), caption = "Other listed resources for Step 1")

Other listed resources for Step 1

Var1	Freq
	121
Dirty Medicine	1
Dirty Medicine YouTube videos	1
NBME and Dr. Legallo's videos and notes from preclinical	1
nbme practice exams	1
NBME practice tests	1
Online MedEd	1
Pixorize	1
Youtube	1

Code

#If you used other resources not listed above, would you use them again?
step1_complete$other_hascontents <- as.integer(nchar(step1_complete$other_resources_step1) > 0) #flagging the rows that have contents https://stackoverflow.com/questions/64744988/testing-to-see-if-characters-are-present-in-a-cell-in-r
mystring1 <- step1_complete %>% filter(other_hascontents == TRUE) %>% select(other_resources_step1, other_step1) 
kable(mystring1, caption = "Other resources and if you'd used them again")

Other resources and if you'd used them again

other_resources_step1	other_step1
Pixorize	Yes, helped immensely with biochemistry and immunology
Dirty Medicine YouTube videos	yes
Dirty Medicine	Yes
nbme practice exams	yes
NBME practice tests	Yes
Youtube	Yes
Online MedEd	Maybe
NBME and Dr. Legallo's videos and notes from preclinical	yes, NBME and Dr. Legallo were the most helpful

What would you change?

Code

step1_complete$change_hascontents <- as.integer(nchar(step1_complete$changes_step1) > 0) 
#as.data.frame(step1_complete[which(step1_complete$change_hascontents == 1), "changes_step1" ])
mystring2 <- step1_complete %>% filter(change_hascontents == TRUE) %>% select(changes_step1) %>% toString() 
cat(str_wrap(mystring2), "\n") #used this package to help it print nicer https://stringr.tidyverse.org/reference/str_wrap.html

c("I would ditch pathoma and just do Anki, UWorld, sketchy and pixorize just
for Biochem and immunology. I would focus my UWorld on things our preclinical
curriculum does not cover well like anatomy, pharmacology, microbiology,
etc. I would focus less on clinical info since we were coming off a year of
clerkships.", "I did it in 3 weeks and it was VERY stressful. However, this
ended up being more than enough time. I would feel reassured that again it is
PASS/FAIL so it will be OK!! ", "Would have started earlier in preclinical -
would have ignored my preclinical classes and used more outside resources to
build foundation. It was difficult to get up to speed for Step 1, and I regret
not studying more in preclinical as I think my Step 2 score would have been
significantly higher. I feel that what was not discussed was how much Step 1
content is still relevant to Step 2.", "I would have studied for 4 weeks instead
of 6 weeks. However, I took my test after thanksgiving so there were less test
dates available. ", "More SketchyMicro. Start using outside resources during
1st year. More UWorld.", "I could have studied less (like 3-4 weeks) because I
was consistently scoring well enough to pass on my practice tests but I was too
nervous to take any chances and decided to instead just use the entire 5 weeks
I had already decided to allocate", "I would make all of my study time part
time (like I did when at home for the first 4 weeks). I wouldn't let classmates
studying 24/7 (unnecessarily in my opinion) stress me out.", "I took about 3
weeks to review Sketchy Micro/Pharm and Pathoma as well as do some Uworld blocks
and practice tests. After scoring so highly on my practice test, I actually
stopped studying except for finishing Sketchy. If I could go back, I would just
incorporate more of Sketchy, Pathoma, and Uworld into pre-dedicated studying
and then just take Step 1 with perhaps 1-2 weeks max of dedicated.", "Focus
more on the things that overlap with step 2", "I just used sketchy/anki for
micro, and that was great. I don't love it for everything, but I think I might
have also tried that combo for some of the biochem. ", "I would have taken the
exam early. I think the school's guidance of waiting until you've gotten 99%
chance of passing on 2 practice tests was probably a bit excessive but without
more information I didn't want to risk not studying as much as possible. ",
"would have done more sketchy, moved through pathoma faster (knew most of it
already from shelf exams/clinical year)", "I would keep a more strict study
schedule in the beginning of my study period.", "Taking a longer period of time
for dedicated. Not done anything else but study during those months ", "Not do
Sketchy path ", "In hindsight, I realize that a more effective approach would
have been to dedicate approximately six weeks to my study plan. During this
time, I would have worked through the entirety of UWorld, Sketchy Micro and
Pharm, as well as Pathoma. Additionally, I would have made it a point to take
every available UWorld and NBME practice test, ensuring that I simulated strict
testing conditions. I should note that my ability to complete only about 25%
of UWorld was somewhat facilitated by my solid foundation from my first year of
medical school and the experience gained from my shelf exams during the PCE.",
"Spent more time studying during pre-clinical years ", "Use less time. 4-5 weeks
is good enough.", "I would have taken Step 1 prior to 3rd year clerkships.",
"I wish it was after pre-clinical year and not after clinical year.", "Since I
took step 1 after clerkships, I did not have to study much. I used it as a prep
time for basic sciences of step 2. I would not have bought World for step 1 as
I would have been fine without it", "I wish we had completed step 1 post pre
clerkship with dedicated time. ", "I would focus on pathophysiology section of
uworld", "It's really not that hard to pass. Just knowing First Aid and going
through UWorld is sufficient.", "I would have started reviewing material (i.e.
watching B&B, Sketchy pharm) before dedicated started so that I could devote
my dedicated time almost exclusively to UWorld questions", "Though I probably
could have studied much less, I did not find the \"% likelihood of passing\"
metric very reassuring and still ended up studying a lot of make sure it was
as reassuring as possible.", "I would probably study really hard for 2 weeks
and take it at the end of the 2 weeks", "I would probably take the test after 2
weeks instead of 3", "I would have taken it immediately after ending clerkships
and then gone off to enjoy my summer. I think many students would be more than
capable of taking the exam following first year before the start of clerkships,
and in many ways I think the increased proximity to many of the basic science
concepts tested on Step 1 would have been a major advantage. Some of the
studying felt like taking a step backwards instead of progressing to try to
advance the depth of my clinical knowledge going into the immersion phase.", "I
ended up taking 12 weeks. M1 was terrible for me and I didn't know how to study.
So, I would go back and study more for it during M1 or M2 but even 12 weeks was
pushing it for me to make up the deficit I was in ", "I took a practice test on
Day 1 of studying, which I did not find helpful. I did poorly on Day 1 and my
score improved by 50 points over 2.5 weeks, so the Day 1 baseline was useless.
I would have studied for slightly longer to feel more confident and take one
more practice exam. I took 1 practice exam pre-studying and 2 after studying. I
passed 1 exam 8 days prior to the test. My study period was 23 days, with days
off during that, and I think near 28 days would have been ideal to feel less
rushed and taken an additional exam. I do not have a great memory, so I felt
like I needed more time, but everyone's different.", "Much more uworld, less
sketchy and anki", "None", "If anything, maybe one less week. It can definitely
be done in 4 weeks but the extra time gave me a comfortable buffer", "I would
have a shorter study period and focused more on step 2", "I would have switched
to timed, untutored mode on U world sooner. On the real exam, my confidence was
so shaky because I was used to the immediate gratification of tutor mode and
being able to take my time to think through the harder questions.", "I wish I
would have started the premade anki deck during M1 instead of at the start of
M2. I finished about 50% of STEP 1 cards and 75% of STEP 2 cards by the time I
took Step 1 and I think it would have been much quicker to a passing score if
i had a higher percentage of STEP 1 cards mastered. I did not use UWorld at all
because I found that reviewing missed questions didn't help me at all. I never
remembered the info or explanations unless I memorized it with anki first. Once
I had things memorized, I had no issues applying the knowledge in exam form.
The only questions I missed were ones that I had never seen on anki.", "Just do
UWorld and know First Aid well, that's all you really need.", "None. ") 

Practice Scores for Step 1 and Step 2

Code

# 11 Practice Scores for Step 1 and Step 2
#   11a  final_nbme_practice_score_step1 is a percent from 0 to 100
ggplot(step1_complete, aes(x = final_nbme_practice_score_step1)) +
  geom_histogram(bins = 30) + 
  theme_minimal() + scale_color_brewer(palette = "Greens") + 
  xlab("Final Step 1 Probability of Passing") + 
  ylab("Count") + 
  ggtitle("What was the probability of passing you received \n on your final NBME form before the Step 1 exam?", subtitle=paste(" answered = ", sum(!is.na(step1_complete$final_nbme_practice_score_step1)), " missing = ", sum(is.na(step1_complete$final_nbme_practice_score_step1))))

Warning: Removed 118 rows containing non-finite values (`stat_bin()`).

Code

#   11b  final_uw_practice_score_step1 is a 3 digit UWorld score for step 1
ggplot(step1_complete, aes(x = final_uw_practice_score_step1)) +
  geom_histogram(bins = 30) + 
  theme_minimal() + scale_color_brewer(palette = "Greens") + 
  xlab("Final Step 1 UWorld Score") + 
  ylab("Count") + 
  ggtitle("What was the 3 digit score you received on your final \n UWorld form before the Step 1 exam?", subtitle=paste(" answered = ", sum(!is.na(step1_complete$final_uw_practice_score_step1)), " missing = ", sum(is.na(step1_complete$final_uw_practice_score_step1))))

Warning: Removed 166 rows containing non-finite values (`stat_bin()`).

3 Appendix/notes

All the analyses are performed using the following: - R version 4.2.2 (2022-06-24); R Core Team (2022). R: A language and environment for statistical computing. R Foundation for Statistical Computing, Vienna, Austria. URL https://www.R-project.org/.

• Harrell Jr FE (2022). rms: Regression Modeling Strategies. R package version 6.3-0, https://CRAN.R-project.org/package=rms.

The table below lists packages used in this document.

Code

subset(data.frame(sessioninfo::package_info()), attached==TRUE, c(package, loadedversion))

                  package loadedversion
cowplot           cowplot         1.1.1
dplyr               dplyr         1.1.3
forcats           forcats         1.0.0
GGally             GGally         2.1.2
ggplot2           ggplot2         3.4.4
glmnet             glmnet         4.1-8
gridExtra       gridExtra           2.3
gtsummary       gtsummary         1.7.2
Hmisc               Hmisc         5.1-1
knitr               knitr          1.44
lubridate       lubridate         1.9.3
Matrix             Matrix         1.5-1
modelsummary modelsummary         1.4.3
plotly             plotly        4.10.2
purrr               purrr         1.0.2
readr               readr         2.1.4
rms                   rms         6.7-1
sandwich         sandwich         3.0-2
scales             scales         1.2.1
stringr           stringr         1.5.0
table1             table1         1.4.3
tibble             tibble         3.2.1
tidyr               tidyr         1.3.0
tidyverse       tidyverse         2.0.0
viridis           viridis         0.6.4
viridisLite   viridisLite         0.4.2
visdat             visdat         0.6.0